Global overview of suicidal behavior and associated risk factors among people living with human immunodeficiency virus: A scoping review

Death by suicide is a major public health problem. People living with human immunodeficiency virus (PLHIV) have higher risk of suicidal behavior than the general population. The aim of this review is to summarize suicidal behavior, associated risk factors, and risk populations among PLHIV. Research studies in six databases from January 1, 1988, to July 8, 2021, were searched using keywords that included “HIV,” “suicide,” and “risk factors.” The study design, suicide measurement techniques, risk factors, and study findings were extracted. A total of 193 studies were included. We found that the Americas, Europe, and Asia have the highest rates of suicidal behavior. Suicide risk factors include demographic factors, mental illness, and physiological, psychological, and social support. Depression is the most common risk factor for PLHIV, with suicidal ideation and attempt risk. Drug overdosage is the main cause of suicide death. In conclusion, the current study found that PLHIV had experienced a high level of suicidal status. This review provides an overview of suicidal behavior and its risk factors in PLHIV with the goal of better managing these factors and thus preventing death due to suicide.


Introduction
Death due to suicide is a major public health problem worldwide. According to the World Health Organization (WHO), approximately 700,000 people died worldwide due to suicide every year (an average of one death every 40 s) [1]. Suicide is a global phenomenon and can occur at any age. Acquired immunodeficiency syndrome (HIV) and human immunodeficiency virus (AIDS) is also a common public health issue, and currently there are more than 37.9 million people living with HIV/AIDS around the world [2]. The rate of suicide deaths in People living with HIV (PLHIV) is 100-fold higher than the rate that has been reported in the general population [3]. Prevalence estimates of suicidal ideation, attempts, and plans among people living with HIV/AIDS were more common and serious than those in the general population [4]. Suicide attempt rates among PLHIV with mental disorders and psychiatric treatment have continued to increase from the pre-highly active antiretroviral therapy (Pre-HAART) era (1988)(1989)(1990)(1991)(1992)(1993)(1994)(1995) to the HAART era (1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008) from 27.8% to 35.1%, respectively [5]. Suicidal behavior is complex, with different levels of severity, ranging from suicidal ideation to suicide attempts and ultimately to the end of life by death due to suicide. Suicidal ideation is defined as thoughts, considerations, or plans to die by suicide, whereas suicide attempts are defined as failed attempts to die by suicide where the person survives [6][7][8]. That suicidal ideation is more common than suicide attempt and death by suicide, and the presence of suicidal ideation increases the risk of suicide attempt and death by suicide. The suggest a complex interrelationship between behavior and suicide attempts [8,9]. Suicidal ideation is an important predictor of subsequent suicide attempts and dying by suicide [9,10].
Suicidal behavior is a complicated process that ranges in degree of severity, from thinking about killing oneself (i.e., suicidal ideation) to doing it (i.e., suicide attempt and death by suicide). In the current study provided insights into the relationships among HARRT, depression, and suicidal status in PLHIV and evidence that depression played a mediating role in the association between suicide ideation and attempt. However, the relationship between these threesuicide behavior is unclear; for example, relationship between HARRT, and death by suicide or depression, and suicide attempts, therefore, this study will be a better feasibility to understanding relationship between these three-suicide behavior and could help prevent suicidal behavior in PLHIV, in whom suicide is a significant public health problem of HIV-infected adults. It is important to categorization of suicidal behaviors among PLHIV due to lack of overview of scope reviewing in this population, even suicide became significant life-threatening event in PLHIV [9].
In general, primary research studies consider only one or two suicidal behavior, such as only suicidal ideation or attempts, or both suicidal ideation and suicide attempts, within a single center or country. Some studies included specific at-risk populations like perinatal women, homosexual men, and prisoners with HIV. However, these studies did not involve all at-risk populations and their risk behavior [11][12][13][14][15][16]. In previous primary research, among PLHIV, poor social support, HIV stigma, mental disorders, and associated comorbidities were associated with increased suicide rates. Improvements in antiretroviral therapy have led to better survival rates in PLHIV; however, suicidal behavior remain a major health issue [17,18].
Thus, exploring suicidal behavior using a wide range of global research studies is vital for primary healthcare professionals to plan early recognition of this and suicide prevention strategies. The aim of this review is to provide an overview of the rates of suicidal behavior and associated suicide risk factors among PLHIV. Detection of suicidal ideation and suicide attempts is important in planning early suicide prevention and optimizing HIV/AIDS management. Rajs, J. et al. (1992) [77] HAART.

Qualitative synthesis
Qualitative synthesis was conducted using data extraction findings to explore the key themes within the selected studies. Three researchers independently conducted the qualitative synthesis on the baseline risk factors of the participants and suicidal ideation rate, suicide attempt rate, and completed suicide rate (Table 1). We created a structural model related to the consistent risk factors after final agreement among all authors.  (Fig 1). All included studies were published as a full article in peer-reviewed journal.

Characteristics of the included studies
According to the WHO regions [22], 69 studies were performed Region of the Americas [9,17,20,, followed by 45 in Europe Region [5,29,31,, 45 in Africa Region [13,18,21,, 26 in Western Pacific Region [9,, 2 in the Eastern Mediterranean Region [191,192], and 6 South-East Asian Region [9,16,168,169,171,181] (Fig 2A). A total of 130 articles were published during the past 10 years (2011-2021) (Fig 2B). There were 121 studies conducted with cross-sectional study designs, 37 cohort studies, 24 retrospective studies, six longitudinal studies, three case-control studies, and two prospective studies (Fig 2C). According to the study settings, 88 studies were conducted in a hospital setting, 35 referenced databases, 64 were conducted in clinics or community centers, 4 were performed in prisons, and 2 were done at palliative care centers (Fig 2D).
107 articles used measurement tools to identify the condition of suicidal behavior and risk factors. There were 66 articles on suicidal ideation, 38 on suicidal attempts, 47 on completed suicide, 39 on suicidal ideation and attempts, 1 on suicidal ideation and death by suicide [95], and three on suicidal ideation, suicide attempts, and completed suicides [78,79,91]. Most of the studies evaluated risk factors; however, 23 did not mention risk factors ( Table 1).
Distribution of death due to suicide around the world. In the Pre-HAART era, from 1988 to 1996, the completed suicide incidence rate was 680.56-4.9per 100,000 person years in the United States [23,25,30,32,195]; 0.5% in the United Kingdom [79]; 25% in the Sweden [77]; 0.47% in the Spain [78]; and 8.13% to 13% in the Netherlands [29, 31]. The death rate due to suicide went from 0.68 per 100 person-years in 1988 to 0.05 in 1996 in the United States [23, 25, 30, 32].

Risk factors for suicide behavior among PLHIV
In this review, the identified causes of death by suicide included drug overdose, gunshot, jumping, drug poisoning, suffocation, and cutting wrists (Table 2). Additionally, we found that suicide-related risk factors included demographic, physiological, social, environmental, and psychological factors (Fig 3).

Measurement tools of the suicide behaviors suicidal behavior and risk factors
Within the included 193 studies, we found that 12 different scales were used to measured suicidal behavior and its risk factors; 26 studies used the Beck depression inventory scale, 8 used the Beck scale for suicide ideation, and 4 used the five-item brief symptom rating scale (Table 3).

Discussion
About 40 million people of the global population are currently living with HIV/AIDS. The era of HAART treatment has brought significant improvements in patient longevity and quality of life [202]; however, PLHIV experience a heavy burden of psychosocial conditions that are frequently undiagnosed and untreated. The pooled incidence of suicide completion among PLHIV globally was 10.2 per 1000 population, translating to a 100-fold greater suicide completion rate compared with the global population rate of 0.09/1000 population for 2019 [3,203]. Therefore, this scoping review of 193 studies included an overview of three types of suicidal behavior among PLHIV as follows: suicidal ideation, suicidal attempts, and dying by suicides. We also included risk factors and associations of suicidal behavior according to demographic, social, physiological, psychological, and environmental factors. We identified consistent and inconsistent risk factors among the three types of suicidal behavior (Fig 3).
In total, this review encompasses 729,189 participants from 49 countries with all eligible articles published during the past 33 years (1988 to 2021). Two-thirds of the studies were published in the last five years (80/193). We found that there was an increasing trend toward conducting research related to suicidal behavior and risk factors among PLHIV globally.
According to the findings of this review, the prevalence rate was highest in the United States, United Kingdom, Australia, and Russia for suicidal ideation, suicide attempts rate was  Table 3. Measurement instrument of suicide.

suicide scales
Beck depression inventory (BDI) 26 [12, 18, 20, 24, 37, 46, 62, 85, 98, 126, 129-134, 137, 138, 164, 167, 169, 172, 176, 177, 180, 187] Beck scale for suicide ideation (BSS) [16,36,46 highest in the United States, Australia, and Spain, and death due to suicide rate was highest in Denmark, and Thailand among PLHIV from 2000 to 2020. The highest suicide ideation rate was in the UK [84], followed by Australia [195], and the US [37]. The highest suicide attempt rate was in Australia [195], with the second highest in Spain [107], and third in South Africa [127]. The highest completed suicide rate was in Denmark [98], followed by Thailand [173], and France [112]. These findings may be since these countries have the most liberal laws on doctor-assisted suicide or gun control or could be due to economic recessions and societal pressure [26,28,204,205]. These differences could be attributed to discrepancies in cultural differences, religious dimensions, and socioeconomic status, and not just by geographical location alone [4]. Previous research has identified psychological disorders and suicide are extremely connected and established in high-income countries, with many suicides occurring impulsively in moments of crisis with a breakdown in the ability to deal with life stresses. This review also found similar results [206,207]. The most frequently used methods used of suicide are hanging and pesticide poisoning in Western countries [17,26,28,30,54,[80][81][82][83]. Reported risk factors for suicide attempts include mental and physical health problems, socioeconomic problems, and drug and alcohol use/ abuse [208] According to our finding in when we considered about South-East Asian Region, most common suicide behavior is death due to suicide, compared with suicide attempts and suicide ideation. Because of educational status of family and social pressure also the social discrimination and stigma are more common in Asian countries than elsewhere in the world [206,207].
Depression and suicidal thinking occur frequently alongside HIV/AIDS, triggering profound detrimental impacts on quality of life, treatment adherence, disease progression, and mortality [177,209]. According to this scoping review, 85 articles dealing with depression, the most common death-related factor for PLHIV is suicide ideation, and their attempted suicide behavior risk is due to depression which is its common cause. Bullying, which includes stigmatization and discrimination, can also drive people to suicide as it increases social isolation. Substance abuse and overdose or severe physical disease are also recognized causes. According to this review findings, Caribbean countries and the Middle East showed the lowest death rates due to suicide.
This study is a global overview of suicidal behavior and associated risk factors among PLHIV. There are some important new findings in this review. First, our review provides both prevalence and incidence rates as well as risk factors for suicide ideation, suicide attempt, and death by suicide among PLHIV. Second, the current study includes findings from diverse populations of patients with HIV from 1988-2021, while previous reviews mostly focused on certain risk populations. Third, our study provides a group association and risk factors for suicidal ideation, suicide attempts, and death due to suicide. Therefore, we believe our findings suggest definite trends and factors that could prevent suicidal behavior among PLHIV, which future studies should examine further.
The limitations of this study were the lack of information regarding ethnic groups, cultural backgrounds, and religious perspectives of suicidal behavior and risk factors among PLHIV. Future studies should focus on these factors prospectively. Also, this large number of studies contained different type of confounding factors and it is difficult to control all confounding one time, however it will not influence to review findings because we would provide overview of suicidal behaviors only. Still did not make any causal relationship furthermore future study designed how to manage confounding such an incident if suicide actions. Also study quality is deferent to each study, not ranked study quality in terms of sample size, biases, etc. same as different scales/ measurement tools were used which also affects consistency in studies can consider some limitations.

Conclusion
This scoping review presents a global view of suicidal behavior in 49 countries and included 193 primary research studies. We found that the Americas, Europe, and some Asia countries have the highest rates of suicidal behavior also after free access of antiviral therapy and post-HAART era, there has been an increasing trend in suicidal behavior. Depression, low quality of life, low social support, substance use, and drug abuse are the most common risk factors for suicidal behavior. Our study lacks information on ethnicity, cultural background, and religious perspectives of PLHIV, and those need to be considered in future studies. This review provides an overview of suicidal behavior and risk factors for future healthcare development plans and prevention of suicide in PLHIV.

Clinical applications
This study will provide data on global suicidal ideation, suicide attempts, and completed suicide as well as the epidemiology and risk factors associated with completed suicides among people living with HIV. The findings of this review can be used as scientific evidence in the design of protocols and clinical practice guidelines intended to manage the wellbeing of PLHIV worldwide. It is also a reference for future researchers who plan to examine suicidal behavior and the risk factors among diverse populations. This study has practical implications for the management of people with HIV and preventing suicide at the global level. Given the high prevalence of suicide in high-risk populations such as people with HIV and the challenges related to preventing suicide, our study findings could support suicide prevention efforts by presenting the prevalence and incidence rates for suicide, as well as the associated risk factors among PLHIV.
Supporting information S1